Provider Demographics
NPI:1063881092
Name:DWIC OF TAMPA BAY, INC
Entity type:Organization
Organization Name:DWIC OF TAMPA BAY, INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CONTRACT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOY
Authorized Official - Middle Name:
Authorized Official - Last Name:KIMBALL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:763-349-6740
Mailing Address - Street 1:423 FORTRESS BLVD
Mailing Address - Street 2:
Mailing Address - City:MORGANTOWN
Mailing Address - State:WV
Mailing Address - Zip Code:26508-1351
Mailing Address - Country:US
Mailing Address - Phone:304-225-2500
Mailing Address - Fax:304-985-6350
Practice Address - Street 1:1120 HOMESTEAD RD N
Practice Address - Street 2:
Practice Address - City:LEHIGH ACRES
Practice Address - State:FL
Practice Address - Zip Code:33936-6044
Practice Address - Country:US
Practice Address - Phone:239-303-5020
Practice Address - Fax:239-303-5053
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-21
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL018097600Medicaid
FLK1515AMedicare PIN